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Prof. Nawwar Al-Attar
Surgery for infective endocarditis is indicated in around a third of patients with active endocarditis and another third after healing of the active process. The indications for surgery should be considered on an individual basis taking into consideration the clinical status of the patient, microbiological and echocardiographic findings. Surgery forms together with adequate antibiotic therapy and intensive medical care, a pillar in the management of infective endocarditis.
Infective endocarditis (IE) is defined as infection of the endocardium. It concerns principally the heart valves other structures' involvement (eg, the septum, chordae tendinae …etc) also falls into this category.
The management of IE is multidisciplinary and is comprised of cardiologists, intensive care physicians and cardiac surgeons. The 3 main pillars are:
The aim of surgery is to improve the survival of the patient and limit damage to the heart valve. The timing of surgical procedures can be early (within 48 hours of antibiotic therapy) or late (after 3 weeks of appropriate antibiotic and medical treatment). Echocardiography (TTE and TEE) plays a key role in the decision making and follow up of these patients. Consequently, surgery may be indicated for any of the following reasons:
Systemic embolisation is detected in approximately 37% of patients (21% of which are asymptomatic). The decision to intervene surgically is taken on an individual basis and is dependant of the embolic risk. Most embolic events occur within the first 2 weeks. The indications of surgery in the presence of stroke are shown in table 1.The following characteristics of the vegetation are considered high risk for embolisation and are potential indications for surgical intervention2:
Urgent surgery is indicated in the presence of a large mobile vegetation on the mitral valve especially if valve repair seems feasible. The appearance of mitral kissing vegetation is another argument in favor of early surgery.
A. Valve repair or plasty: this is always preferred whenever possible. It is more potentially applicable to the atrio-ventricular valves (mitral and tricuspid valves) (figure 3). Early surgery has shown higher rates of valve repair and is associated with better outcomes3. B. Valve replacement: excision of a severe damaged valve can be the only surgical option as is the case for prosthetic valve endocarditis. In either case, all necrotic and infected tissue needs to be excised and sent for bacterial culture, special culture and if necessary PCR. The defects need to be repaired:
Mitral valve repair can be performed in 2/3 of cases. This can be undertaken early after the onset of the disease and before major tissue loss or destruction has occurred.
Homografts have supposedly greater resistance to infections compared to prosthetic valves and their use is especially useful when aortic valve endocarditis is associated with left ventricular outflow tract lesions. However, they are fraught with high early calcification rates and the problems of availability. Translocation of the aortic valve can be a useful alternative especially in patients with prosthetic valve endocarditis4.
Table 1. Surgical considerations in the presence of stroke :
Symptom : ManagementTIA with normal CT scan : Early surgery if high risk for repeat embolisation &/or multiple emboliNon hemorrhagic stroke : Unless surgery can be performed <72 hrs and CT scan excludes cerebral hemorrhage, delay surgery for 2-3 weeks (risk of complications with CPB)Hemorrhagic stroke : Delay surgery for 3-4 weeks because of major neurological riskComa : Contraindication to surgery since the prognosis is dependent on the neurological status of the patient
Figure 1. Large perforation of the anterior mitral valve with a large vegetation
Figure 2. Abscess of the aortic annulus
Figure 3. Repair of a perforation of the anterior mitral valve by pericardial patch. Mitral annuloplasty was also performed.
1. Vikram HR, Buenconsejo J, Hasbun R, Quagliarello VJ. Impact of valve surgery on 6-month mortality in adults with complicated, left-sided native valve endocarditis: a propensity analysis. JAMA. 2003;290(24):3207-14. 2. Thuny F, Di Salvo G, Belliard O, Avierinos JF, Pergola V, Rosenberg V, Casalta JP, Gouvernet J, Derumeaux G, Iarussi D, Ambrosi P, Calabró R, Riberi A, Collart F, Metras D, Lepidi H, Raoult D, Harle JR, Weiller PJ, Cohen A, Habib G. Risk of embolism and death in infective endocarditis: prognostic value of echocardiography: a prospective multicenter study. Circulation 2005;112(1):69-75. 3. Feringa HH, Shaw LJ, Poldermans D, Hoeks S, van der Wall EE, Dion RA, Bax JJ. Mitral valve repair and replacement in endocarditis: a systematic review of literature. Ann Thorac Surg. 2007;83(2):564-70. 4. Al-Attar N, Nottin R, Ramadan R, Azmoun A. Translocation of the aortic valve in severe aortic root abscess. An alternative to homografts. Eur J Cardiothorac Surg. 2005;28(3):509-10;
5. Horstkotte D, Follath F, Gutschik E, Lengyel M, Oto A, Pavie A, Soler-Soler J, Thiene G, von Graevenitz A, Priori SG, Garcia MA, Blanc JJ, Budaj A, Cowie M, Dean V, Deckers J, Fernández Burgos E, Lekakis J, Lindahl B, Mazzotta G, Morais J, Oto A, Smiseth OA, Lekakis J, Vahanian A, Delahaye F, Parkhomenko A, Filipatos G, Aldershvile J, Vardas P; Task Force Members on Infective Endocarditis of the European Society of Cardiology; ESC Committee for Practice Guidelines (CPG); Document Reviewers. Guidelines on prevention, diagnosis and treatment of infective endocarditis executive summary; the task force on infective endocarditis of the European society of cardiology. Eur Heart J. 2004;25(3):267-76.
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